Cervical cancer - Treating cervical cancer

The treatment for cervical cancer depends on how far the cancer has spread.

Deciding which treatment is best for you can often be confusing, which is why hospitals use multidisciplinary teams (MDTs) to treat cervical cancer. MDTs are made up of a number of different specialists who work together to make decisions about the best way to proceed with your treatment.

Your cancer team will recommend what they think the best treatment options are, but the final decision will be yours.

In most cases, the recommendations will be:

• early cervical cancer – surgery to remove some or all of the womb, radiotherapy, or a combination of the two
• advanced cervical cancer – radiotherapy and/or chemotherapy, although surgery is also sometimes used

The prospect of a complete cure is good for cervical cancer diagnosed at an early stage, although the chances decrease the further the cancer has spread.

Even in cases where cervical cancer isn't curable, it's often possible to slow its progression, prolong lifespan and relieve any associated symptoms, such as pain and vaginal bleeding. This is known as palliative care.

The different treatment options are discussed in more detail below.

Removing abnormal cells

If your screening results show that you don't have cervical cancer but there are biological changes that could turn cancerous in the future, a number of treatment options are available. These include:

• large loop excision of the transformation zone (LLETZ) – the abnormal cells are cut away using a fine wire and an electrical current
• cone biopsy – the area of abnormal tissue is removed during surgery
• laser therapy – a laser is used to burn away the abnormal cells

Read more about treating abnormal cells in the cervix.

Surgery

There are three main types of surgery for cervical cancer. They are:

• radical trachelectomy – the cervix, surrounding tissue and the upper part of the vagina are removed but the womb is left in place
• hysterectomy – the cervix and womb are removed; depending on the stage of the cancer, it may also be necessary to remove the ovaries and fallopian tubes
• pelvic exenteration – a major operation in which the cervix, vagina, womb, bladder, ovaries, fallopian tubes and rectum are removed

The three types of surgery are discussed below.

Radical trachelectomy

A radical trachelectomy is usually only suitable if cervical cancer is diagnosed at a very early stage. It is usually offered to women who want to preserve their child-bearing potential.

During the procedure, the surgeon will make a number of small incisions (cuts) in your abdomen. Specially designed instruments will be passed through the incisions and used to remove your cervix and the upper section of your vagina. Lymph nodes from your pelvis may also be removed. Your womb will then be reattached to the lower section of your vagina.

Compared with a hysterectomy or pelvic exenteration, the advantage of this type of surgery is that your womb remains intact, which means that you may still be able to have children. However, it is important to be aware the surgeons carrying out this operation cannot guarantee you will still be able to have children.

If you do have children after the operation, your child would have to be delivered by caesarean section (where the baby is removed through an incision in your abdomen). It's also usually recommended that you wait six to 12 months after having surgery before trying for a baby so that your womb and vagina have time to heal.

Radical trachelectomy is a highly skilled procedure. It's only available at a number of specialist centres in the UK, so it may not be available in your area and you may have to travel to another city to be treated.

Hysterectomy

A hysterectomy is usually recommended for early cervical cancer. This may be followed by a course of radiotherapy to help prevent the cancer coming back.

Two types of hysterectomies are used in treating cervical cancer. They are:

• simple hysterectomy – where the cervix and womb are removed and, in some cases, the ovaries and fallopian tubes are also removed; this is only appropriate for very early stage cervical cancers
• radical hysterectomy – where the cervix, womb, surrounding tissue and lymph nodes, ovaries and fallopian tubes are all removed; this is the preferred option in advanced stage one and some early stage two cervical cancers

Short-term complications of a hysterectomy include infection, bleeding, blood clots and accidental injury to your ureter, bladder or rectum.

The risk of long-term complications is small but they can be troublesome. They include:

• your vagina can become shortened and drier, which can make sex painful
• urinary incontinence
• swelling of your arms and legs caused by a build-up of fluid (lymphoedema)
• your bowel becomes obstructed because of a build-up of scar tissue – this may require further surgery to correct

As your womb is removed during a hysterectomy, you will no longer be able to have children.

If your ovaries are removed, it will also trigger the menopause if you haven't already experienced it. See complications of cervical cancer for more information about the menopause.

Pelvic exenteration

A pelvic exenteration is a major operation that's usually only recommended when cervical cancer returns after what was thought to be a previously successful course of treatment. It is offered if the cancer returns to the pelvis but hasn't spread beyond this area.

A pelvic exenteration involves two phases of treatment:

• the cancer is removed, plus your bladder, rectum, vagina and the lower section of your bowel
• two holes called stomas are created in your abdomen – the holes are used to pass urine and faeces out of your body into collection pouches called colostomy bags

Following a pelvic exenteration, your vagina can be reconstructed using skin and tissue taken from other parts of your body. This means that you'll be able to have sex after the procedure, although it may be several months until you feel well enough to do so.

Radiotherapy

Radiotherapy may be used on its own or combined with surgery for early stage cervical cancer. It may be combined with chemotherapy for advanced cervical cancer, where it can be used to control bleeding and pain.

There are two ways that radiotherapy can be delivered. These are:

• externally – a machine beams high energy waves into your pelvis to destroy cancerous cells
• internally – a radioactive implant is placed inside your vagina and cervix

In most cases, a combination of internal and external radiotherapy will be used. A course of radiotherapy usually lasts for around five to eight weeks.

As well as destroying cancerous cells, radiotherapy can sometimes also harm healthy tissue. This means it can cause significant side effects many months and even years after treatment.

However, the benefits of radiotherapy often tend to outweigh the risks. For some people, radiotherapy offers the only hope of getting rid of the cancer.

Side effects of radiotherapy are common and can include:

• diarrhoea
• pain when urinating
• bleeding from your vagina or rectum
• feeling very tired (fatigue)
• feeling sick (nausea)
• sore skin in your pelvis region similar to sunburn
• narrowing of your vagina, which can make having sex painful
• infertility
• damage to the ovaries, which will usually trigger an early menopause (if you haven't already experienced it)
• bladder and bowel damage, which could lead to incontinence

Most of these side effects will resolve within about eight weeks of finishing treatment, although in some cases they can be permanent. It is also possible to develop side effects several months or even years after treatment has finished.

If infertility is a concern for you, it may be possible to surgically remove eggs from your ovaries before you have radiotherapy so that they can be implanted in your womb at a later date. However, you may have to pay for this.

It may also be possible to prevent an early menopause by surgically removing your ovaries and replanting them outside the area of your pelvis that will be affected by radiation. This is known as an ovarian transposition.

Your MDT will be able to provide more information about the possible options for treating infertility and whether you're suitable for an ovarian transposition.

Chemotherapy

Chemotherapy can be combined with radiotherapy to try to cure cervical cancer, or it can be used as a sole treatment for advanced cancer to slow its progression and relieve symptoms (palliative chemotherapy).

Chemotherapy involves using either a single chemotherapy medication called cisplatin or a combination of different chemotherapy medications to kill the cancerous cells. 

Chemotherapy is usually given using an intravenous drip on an outpatient basis, so you'll be able to go home once you have received your dose.

As with radiotherapy, these medications can also damage healthy tissue. Side effects are therefore common and can include:

• feeling sick
• being sick (vomiting)
• diarrhoea
• feeling tired all the time
• reduced production of blood cells, which can make you feel tired and breathless (anaemia) and vulnerable to infection because of a lack of white blood cells
• mouth ulcers 
• loss of appetite
• hair loss – your hair should grow back within three to six months of your course of chemotherapy being completed, although not all chemotherapy medications cause hair loss

Some types of chemotherapy medication can damage your kidneys, so you may need to have regular blood tests to assess the health of your kidneys.

Follow-up

After your treatment has been completed and the cancer has been removed from your body, you will need to attend regular appointments for testing. This will usually involve a physical examination of your vagina and your cervix, if it hasn't been removed.

As there is a risk of cervical cancer returning, these examinations are used to look for signs of this. If anything suspicious is found, a further biopsy can be performed.

In cases where cervical cancer does return, this usually occurs around 18 months after a course of treatment has been completed.

Follow-up appointments are usually recommended every four months after treatment has been completed for the first two years, and then every six to 12 months for a further three years.